Reduce Readmissions with Whole Person Data

How Whole Person Care Can Reduce Hospital Readmissions 

Reducing hospital readmissions is a critical goal for healthcare providers, not only to improve patient outcomes but also to lower healthcare costs. Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age, and they have a significant impact on health outcomes. By addressing these factors, provider organizations can implement more effective interventions to reduce the likelihood of readmissions.  

This is a subject discussed at length at conferences and in business meetings, but it has become very relevant in my personal life over the past few years. As I watch my parents and other family members in their generation get older, I can immediately see a vast difference in the care where healthcare organizations are leveraging data to understand their high-risk patients better versus those that have not. For example, a common social factor that can be a barrier to care is transportation. If you are aware of this, before or during a hospital stay, you can work on an intervention to be sure patients without transportation are able to make it to their follow-up appointment. I have seen this intervention in action personally.  

Identifying patients that have lack of transportation and providing solutions can impact care tremendously. My grandmother’s health plan helped my mother arrange a pickup and drop off so that my grandmother could stay on schedule with dialysis appointments. Her prognosis and overall health greatly stabilized after transportation was provided. Prior to that, she was readmitted three times due to issues with her kidneys. It was clear that the health plan and provider’s assistance made a significant impact on her health outcome. 

To deliver the right care to the right people, you need to know the population you serve and using healthcare SDOH is a way to do that. After determining the needs, you can develop an intervention strategy. Preventing hospital readmissions is better for patients and helps reduce organization costs. Here are ways healthcare organizations can use SDOH data to better address their high-risk patients’ needs and improve outcomes:

1.Identifying High-Risk Patients

The first step in addressing readmissions through healthcare SDOH is identifying patients at high risk of readmission. These are often patients who live in poor socio-economic conditions. Tools like the Area Deprivation Index can help providers. Provider organizations can use SDOH data to identify patients from high-risk areas by analyzing neighborhood-level data on income, education, employment and housing quality.¹ By using data, healthcare providers can target interventions more effectively. 

2. Comprehensive Discharge Planning 

Effective discharge planning that considers SDOH can significantly reduce readmissions. This involves not only medical instructions but also addressing barriers that might prevent a patient from following through with post-discharge plans. By teaching patients what they need to do after discharge, the UCSF Medical Center program found that its teach-back methodology cut readmission rates 30%.² 

Also important when discharging patients is ensuring access to transportation for follow-up appointments, understanding if the patient has a stable living condition, or if they have access to nutritious food. Tailoring discharge plans to address these factors can help in reducing the likelihood of a patient returning to the hospital.³ 

3. Partnering With Community Organizations

Partnering with community organizations can provide support to patients outside the hospital setting. These partnerships can offer various services, including home health care, meal deliveries or assistance with transportation. For example, collaborations with local food banks or meal delivery services can ensure patients have access to nutritious food, which is crucial for recovery and can prevent complications that might lead to readmissions.⁴

4. Engaging Patients 

Engaging the patient is crucial in monitoring patients post-discharge and ensuring they adhere to their treatment plans. Reminding patients to take their medications, track their symptoms and even provide educational resources about their health conditions. This constant engagement helps in managing chronic conditions⁵ more effectively and reduces the risk of readmission.⁶ 

5. Providing Regular Follow-Up and Support 

Regular follow-up appointments can help healthcare providers catch and address potential issues before they require rehospitalization. Additionally, providing patients with support through community health workers or patient navigators who can communicate with them in their primary language and understand their cultural context can enhance patient engagement and adherence to prescribed health regimens.⁷   

Knowing your population needs help gives your organization the direction needed to help improve health outcomes for patients with social factors that can be a barrier to care. Like in the scenario with my grandmother, the ability for a provider or health plan to act on patient-level barriers to care can change the trajectory of a prognosis or life expectancy. Addressing social determinants of health is a powerful strategy for whole person care and reducing hospital readmissions. By identifying high-risk patients, enhancing discharge planning, forming community partnerships and engaging patients, healthcare providers can significantly improve patient outcomes and reduce readmissions. These strategies not only address the medical needs of patients but also the environmental and social challenges that influence their health.  

If you’re ready to build your SDOH strategy, read this white paper,

“Building a Social Determinants of Health Data Strategy:  3 Key Steps for Healthcare Organizations.” 

References:

1. Singh, G. K. (2019). Area Deprivation and Widening Inequalities in US Mortality, 1969-2013. American Journal of Public Health.
2. “UCSF Medical Center Cuts Heart Failure Readmission Rates by 30 Percent,” UCSF, July 6, 2011, https://www.ucsf.edu/news/2011/07/98349/ucsf-medical-center-program-cuts-heart-failurereadmission-rate-30-percent. 
3. Jack, B. W., et al. (2009). A Reengineered Hospital Discharge Program to Decrease Rehospitalization. Annals of Internal Medicine.
4. Berkowitz, S. A., et al. (2018). Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare And Medicaid Beneficiaries. Health Affairs.
5. Strategies for Patient, Family, and Caregiver Engagement [Internet], National Library of medicine
6. Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning, Agency of Healthcare Research and Quality.
7. Kangovi, S., et al. (2014). Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Clinical Trial. American Journal of Public Health.